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KISHWAUKEE COLLEGE

ATHLETE PERSONAL DATA FORM

Last Name ___________________________ First Name ______________________ Middle Name _____________

Home Address _____________________________ __________________________ _____________Street Address City Zip Code

School (Local) Address _____________________________ __________________________ _____________Street Address City Zip Code

Cell Phone # ( ) Social Security Number ____________________________

Date of Birth ____/_____/______ Year in College _________ Sport ___________________

Emergency Contact Person: ________________________________ Relationship: __________________________First Name Last Name (Parent/Guardian, Aunt/Uncle, Sibling, Grandparent, Friend)

Emergency Contact Phone Number (s): (___)__________________ __(____)______________________________

Family Physician _________________________________________________________________________Name City State Phone #

PERSONAL INFORMATION — Please fill out as completely as possible

What is a little known fact about yourself?

List any interesting, non-athletic hobbies, talents or unusual facts about yourself that could be useful in a feature story:

Any other personal tidbits that people would find interesting about your life that would make a good feature story or human interest story (i.e. overcoming a personal or family tragedy, a handicap, etc.)?

Who is your personal hero/idol and why?

Favorite Sports Team(s):

Favorite Professional Athlete(s):

Favorite Song:

Favorite Music Artist:

Favorite Movie:

Favorite Sports Movie:

Favorite Food:

Why did you choose Kishwaukee College?

What do you like most about Kishwaukee College?

Incoming Freshman/Transfer

HIGH SCHOOL BACKGROUND

High School Attended: *

High School Graduation Year: *

High School Sports Played (Years & Letters Won):

High School Honors, Specify Sport and Year (All-League, All-State, etc.):

Did any teams you were on ever win a conference, county or state championship, include summer teams as well (Please list sport, championship and year won)?

Did you win any individual championships (Please list sport, championship and year won)?

MEDIA INFORMATION

Hometown Newspapers (Name, City & State):

What is your Twitter handle (example: @KishKougars):

What is your Instagram Handle (example: @KishKougars):

TRANSFERS ONLY

Previous College:

Previous College Honors:

Letters Won and Years Played at Previous School:

Kishwaukee College Athlete Code of ConductEach student-athlete accepts responsibility above and beyond that of the general student body with regard to his/her conduct as a representative of the College. It is a privilege, not a right to be a member of a Kishwaukee College Athletic Team, and therefore, he/she is held to a higher standard. Each student-athlete will abide by the Student-Athlete Code of Conduct, policies and procedures, as well as the rules and regulations that have been established by Kishwaukee College, the Arrowhead Athletic Conference, Region IV and the National Junior College Athletic Association.

1. Eligibility – It is the responsibility of each student-athlete to maintain good academic standing. Each athlete must meet the eligibility requirements established by the (NJCAA); this includes making satisfactory progress in classes and maintaining full-time enrollment (12 hours prior to the last regular season game) during each semester throughout the academic year. Failure to meet these requirements will result in immediate expulsion from the athletic program(s).

2. Representing Kishwaukee College – An athlete is seen in the public eye more often than the average student. It is a privilege to be a college athlete with class and dignity. Failure to do this will result in disciplinary action from the coach and/or Athletic Director.

3. Use of College Property – All equipment and/or uniforms issued to a student-athlete must be returned in satisfactory condition to the Head Coach within three days of his/her last contest. Student-athletes will be financially responsible for the replacement costs of lost, stolen, or damaged property. Failure to comply will result in a “hold” being placed on your account.

4. Alcohol, Tobacco and Drug Use – The college policy states that each student-athlete refrains from illegal substances at all times. The NJCAA bans the use of alcohol, drugs and all tobacco products during any athletic related event, scrimmage, practice, travel, or games. Failure to comply will be treated on an individual basis and may be grounds for suspension and/or dismissal from the team. Student athletes may be subjected to random drug testing during each semester. Failure to comply with a testing request is considered an admission of use.

5. Disturbance in Public – Athletes are only one group that uses Kishwaukee College facilities. Usage is shared with instructional classes and members of the community. We expect athletes to act in a mature manner at all times and not create a situation that disrupts or disturbs another program. Student-athlete behavior off-campus will also be closely monitored. Any violations or conduct deemed inappropriate will result in probation, suspension or dismissal from his/her team.

6. Dress and Appearance – Proper attire is required. Moderation and good taste are always expected.

7. Responsibility – If you want to be treated as an adult, you simply have to act like one. As an adult, you are responsible for your actions, which mean accepting the decisions of your coaches or the athletic department administration graciously and in a mature manner.

8. Academic Integrity – Kishwaukee College’s Policy on Academic Integrity is in the Student Handbook. If you cheat, fabricate, facilitate academic dishonesty, or plagiarize, there will be serious consequences. The incident will be documented and reported to the academic chair for possible disciplinary actions up to and including course, program or College expulsion.

9. Hazing – Occurs when you intentionally, knowingly or recklessly do something to another person that you know or should know may endanger the physical safety or health of that person for the purposes of pledging, joining, participating in, or maintaining membership within an organization, such as a fraternity, sorority, club, service group, social group, or athletic team. Hazing is illegal in the State of Illinois and is punishable by both imprisonment and monetary fines. Prison time and the amount of money owed increase depending upon the severity of the harm caused.

10. Social Networking Policy – As members of the Athletic Department, student-athletes’ represent the College and are subject to public scrutiny. Student-athletes will be held responsible for any social networking conduct that compromises the reputation or integrity of their team and/or College. Before posting anything on a social networking website, understand that anything posted online is available to anyone in the world to and that college coaches or staff may monitor the website.

I understand it is a privilege, not a right to be a member of a varsity athletic team at Kishwaukee College, and I agree to abide by all components of the Student-Athlete Code of Conduct

____________________________________________ ________________________________________Student-Athlete’s Printed Name Student-Athlete’s Signature

____________________________________________Date

NJCAA Eligibility Affidavit

SPORT: _________________________ Date: _____________

Fill in all applicable information on this form to assist in determining eligibility for the NJCAA.

Name: ____________________ Birth Date: __/__/____ Social ____________ Security #: ___-___-_____

(First, Middle, Last)

College Address: _______________________________ __________________________________

Street Address City, State, Zip Code

Phone Number(s): ___________________________ Email Address______________________________

Personal Information:

Home Address: _________________________________________________________________

Street Address City, State, Zip Code

Phone Number: ________________________________ Parents’ Names: ________________________________

Are you a United States Citizen or a Permanent Resident*? Yes _____ No _____ (*Holder of a Green Card or F1 VISA)

Are you on another type of VISA? Yes _____ No _____ If so, what type? __________________________________

High School Information:

High School(s) Attended: ________________________ City, State & Country: _____________________

Graduated?: Yes* _____ No _____ High School Graduation Date (month/year): ____/______

Check here if you have earned a *GED: ______ GED: Date Earned (month/year): ____/______

* Enclose a COPY of your High School Diploma or GED Certificate

Additional Information:

1. Did you take any college credit classes while in high school? Yes* _____ No _____

* If yes, from what college(s)? _________________________________________________________

* If yes, please furnish transcript(s) from each college.

2. Have you ever signed a Letter of Intent form with any institution? Yes _____ No _____

If yes, specify the College: __________________________________ Date (day/month/year): ____/____/______

3. Have you ever participated in a sport in a country other than the United States? Yes _____ No _____

If yes, describe the situation and complete the following: __________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________

Sport(s)? _______________________ Country: ________________________ Dates: ___________________

4. Have you ever been red-shirted for a season? Yes _____ No _____

If yes, list when, where, and describe the situation. _____________________________________________

______________________________________________________________________________

______________________________________________________________________________

5. Have you ever participated in practices/tryouts/exhibitions/scrimmages/games for an intercollegiate team other than this college? Yes _____ No _____ If yes, name the school, date, sport, and describe the situation. __________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

6. Have you ever played on a club team at a college or university? Yes _____ No _____ If yes, name the school,

sport and the dates. ______________________________________________________________________________

_______________________________________________________________________________________________

7. Have you ever received money beyond expenses for participating in any athletic event? Yes _____ No _____

If yes, describe the situation. ______________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

List ALL Colleges Attended Full-Time and/or Part-Time after High School

All transcripts from all previous institutions must be included.

College: ___________________________________ Dates: _____________________ Full-time or Part-time? (circle one)




Additional Explanations:

NOTE: If you attended college part-time or were not attending at all for any periods of time following high school

graduation, please document your employment and military history during those times. If you were unemployed at any time, please list those dates as well. The NJCAA requires that we account for any time not enrolled full-time. Please use the space below. Please record months and years when referring to dates. ______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

I understand that information falsified or omitted can make me ineligible for ALL future college competition in

compliance with the National Junior College Athletic Association Eligibility Rules.

Student-Athlete Signature: ______________________________________________ Date: ______________________

Coach Signature: _____________________________________________________ Date: ______________________

KISHWAUKEE COLLEGE

STUDENT ATHLETE CONCUSSION COMPLIANCE STATEMENT

I understand that it is my responsibility to report all injuries/illness to KC Sports Medicine Staff and/or the team physician.

I have read and understand the NCAA Concussion Fact Sheet

AFTER READING THE NCAA CONCUSSION FACT SHEET, I AM AWARE OF THE FOLLOWING INFORMATION:

A concussion is a brain injury, which I am responsible for reporting the KC Sports Medicine StaffINITIAL

A concussion can affect my ability to perform everyday activities and affect reaction time, balance, sleep, concentration, and classroom performance.

INITIAL

Concussions do NOT always cause loss of consciousness. Some of the common symptoms include: headache, memory issues, nausea, dizziness, blurred vision, feeling like in a “fog”, sensitivity to bright lights and loud noises.

INITIAL

You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up HOURS or DAYS after the injury.

INITIAL

If I suspect that I or a TEAMMATE has a concussion. I am responsible for reporting the possible injury to the KC Sports Medicine Team.

INITIAL

I WILL NOT RETURN TO PLAY in the game or practice if I have received a blow to the head or body that results in concussion related symptoms

INITIAL

Following a concussion, the brain needs time to heal. I are much more likely to have a repeat concussion if I return before my symptoms resolve.

INITIAL

In rare cases, repeat concussions can cause permanent brain damage; and in severe cases death.INITIAL

I agree to do the following in the event I sustain a concussion or think that I may have sustained a concussion:

1. I WILL NOT HIDE IT. I WILL TELL THE KC SPORTS MEDICINE STAFF AND MY COACH.2. I WILL REPORT THE CONCUSSION – I WILL NOT CONTINUE TO PLAY IN A GAMEO OR

PRACTICE WITH SYMPTOMS.3. I WILL GET CHECKED OUT – I WILL SEE THE KC SPORTS MEDICINE STAFF AND TEAM

PHYSICIAN FOR TREATMENT AND CARE.4. I WILL TAKE TIME TO RECOVER. I WIL NOT RETURN TO PLAY UNTIL CLEARED BY THE TEAM

PHYSICIAN AND PERFORMED MY “RETURN TO PLAY PROTOCOL” WITH THE KC SPORTS MEDICINE STAFF.

I ________________________________________________________have carefully read the Kishwaukee College Concussion Compliance Document. I agree to report any concussions or suspected concussion episode(s) to the KC Sports Medicine Team. I further state that the information above pertaining to head injuries and concussion in sport has benefited me educationally and made me more aware of the risks and dangers associated with concussions. I agree to do my part and be responsible for reporting head injuries and concussions to the Kishwaukee College Sports Medicine Team.

_______________________________________________________________________ Date:______/_______/________Signature

Sport(s):____________________________________________________________________________

ACKNOWLEDGMENT AND ASSUMPTION OF ATHLETIC RISK AND RESPONSIBILITY FOR REPORTING INJURY AND ILLNESS

Student-Athlete’s Name: _____________________________ Sport(s): ________________________________________

Training, traveling and participation in intercollegiate sports requires a personal acceptance of risk of serious injury. The risk of injury is an inescapable part of physical athletic training and competition.

I understand that training, traveling, and participation in Intercollegiate Athletic at Kishwaukee College may involve accidents resulting in injury/illness, permanent physical or mental impairment, or even death. These injuries may be minor or may be career- or life-threatening. I understand that Kishwaukee College is not responsible for any injuries or conditions which may be caused by the actions of third parties, other Kishwaukee College student-athletes, other teams and their student-athletes, or myself. I further understand and I assume the risk that I may have personal physical conditions that may appear during my training, conditioning, or participation in competition that my coaches, athletic trainers, and medical support providers may not know about that can cause me unanticipated injury/illness, permanent physical or mental impairment, or even death. I also understand that injuries may be caused by my own failure to follow safety procedures or techniques that are made known to me by my coaching staff, Sports Medicine Staff, or by the Strength and Conditioning Staff, or are otherwise known by any other source including but not limited to medical personnel servicing me by virtue of their relationship to Kishwaukee College.

I have read the above risk statement. I acknowledge the fact that these various risks exist and I am voluntarily willing to personally assume any and all such risks by virtue of my participation in Intercollegiate Athletics at Kishwaukee College. In consideration for my being permitted to participate, I also agree as follows:

A. I voluntarily assume all risks associated with my participation in Intercollegiate Athletics at Kishwaukee College.

B. I agree that Kishwaukee College and its employees, officers, directors, and agents are not to be held responsible for any pre-existing medical condition(s) that I may have.

C. I understand that having passed the physical examination only means that the examination did not find a medical reason to disqualify me at the time of the physical examination. It does not necessarily mean that I am physically qualified to participate in Intercollegiate Athletics at Kishwaukee College. If I develop an injury or illness during my participation in Intercollegiate Athletics at Kishwaukee College, including during practice and competition, I will immediately inform my Athletic Trainer or the nearest member of the Sports Medicine Staff. I understand that I must be honest in reporting the symptoms of my injury or illness, and that it is my responsibility to follow any and all treatment and rehabilitation instructions that I am given.

D. I understand that I must refrain from practice while injured or ill, whether or not I am receiving medical care. When under medical care I may not return to participation until I have been given permission by my Team Physician. I understand that if I practice while injured or ill and/or if I return to participation in Intercollegiate Athletics at Kishwaukee College before I have been given permission by my Team Physician, Kishwaukee College and its employees, officers, directors, and agents are not responsible for any consequences I may suffer, including, but not limited to, further injury or illness.

E. I understand and agree that if I experience an injury/illness or a change in my health status it is my responsibility to inform my Head Coach and Athletic Trainer in charge of my sport and it is my responsibility to adhere to the established injury management guidelines, which requires total rehabilitation and reassessment before I am released to resume participation in Intercollegiate Athletics at Kishwaukee College.

F. Governing Law and Jurisdiction. The laws of the State of Illinois shall govern the construction, validity, and enforceability of this Agreement, without giving effect to its conflict of laws principles. All suits, actions, claims, and causes of actions relating to the construction, validity, performance, and enforcement of this Agreement shall be in the State of Illinois Court of Claims.

I understand, accept, and agree that, while I am under no obligation to sign this form and consent to these terms, my refusal to sign/consent or my withdrawal of consent to this Acknowledgment and Assumption of Risk and Responsibility for Reporting Injury and Illness will make me ineligible to participate in Intercollegiate Athletics at Kishwaukee College.

By signing below, I acknowledge and represent that I have read this Acknowledgment and Assumption of Risk and Responsibility for Reporting Injury and Illness in its entirety, understand it, and voluntarily sign it as my own free act and deed, and that I execute this Acknowledgment fully intending to be bound by the same.

__________________________________________________ __________________________________________ Student-Athlete Signature Date Student-Athlete Print Name

__________________________________________________ __________________________________________ Parent Signature (If Athlete is a Minor) Date Parent Print Name

AUTHORIZATION TO TREAT STATEMENT


I authorize the Kishwaukee CollegeSports Medicine Staff and Team Physicians to provide me with sports medicine services and routine medical care (including making health decisions) as part of my participation in Intercollegiate Athletics at Kishwaukee College. This care may include the prevention of injuries, first aid and injury management, evaluating injuries and rehabilitating injuries. I accept the responsibility for reporting my injuries and illnesses to the KC Sports Medicine Staff and/or Team Physicians, including signs and symptoms of concussions. Furthermore, I do hereby authorize the KC Sports Medicine Staff to seek emergency medical care from outside clinicians and medical personnel and release information to the appropriate personnel if they feel it necessary.

I understand, accept, and agree that, while I am under no obligation to sign this form and consent to these terms, my refusal to sign/consent or my withdrawal of consent to this Authorization to Treat Statement will make me ineligible to participate in Intercollegiate Athletics at Kishwaukee College.

By signing below, I acknowledge and represent that I have read this Authorization to Treat Statement in its entirety, understand it, and voluntarily sign it as my own free act and deed, and that I execute this Authorization fully intending to be bound by the same.



AUTHORIZATION FOR USE, DISCLOSURE, AND RELEASE OF HEALTH INFORMATION


I authorize the following persons (or class of persons) to access, review, and make authorized use and/or disclosure of my protected health information: Kishwaukee College Sports Medicine Department Staff and Team Physicians, consulting physicians, athletic trainers, physical therapists, Kishwaukee Student Health and Counseling Services, any secondary insurance providers including 1 st Agency Insurance, and my parents/guardians.

RELEASE OF PROTECTED HEALTH INFORMATION TO:I authorize the following persons (or class of persons) to receive my protected health information: Kishwaukee College Sports Medicine Department Staff and Team Physicians, KC Athletic Directors and Administration, KC Coaches, third parties for insurance and billing purposes, and other healthcare providers for diagnosis or treatment purposes.

INFORMATION TO BE RELEASED INCLUDES: Medical History, Examination, Reports Surgical Records Prescriptions Treatment or Tests Hospital Records & Reports X-ray Reports Allergy Records Laboratory Reports MRI Reports Consultations Immunizations

SPECIAL RELEASE PERMISSION:In compliance with New York and Federal Statutes, which may require special permission to release otherwise confidential and/or privileged information, I am also authorizing the release of records pertaining to: Mental Health Developmental Disabilities Alcoholism HIV/AIDS Sexually Transmitted Diseases Drug Abuse

PURPOSE FOR DISCLOSURE INCLUDES: Health and Injury Status for Athletics Legal Investigation or Action Medical Ability/Fitness to Participate in Athletics Consulting Physicians Insurance Eligibility/Benefits Further Medical Care

YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION:Right to Inspect or Copy the Health Information to be Used or Disclosed- I understand that I have the right to inspect or copy the health information I have authorized to be used or disclosed by this authorization form. I may arrange to inspect my health information or obtain copies of my health information by contacting the Head Athletic Trainer.Right to Receive Copy of This Authorization- I understand that if I agree to sign this authorization, I have the right be provided with a signed copy of this form.

Non-Discrimination- I understand that it is against Kishwaukee College policy to discriminate on the basis of disability and/or genetic information. If I experience discrimination because of the release of my health information pursuant to this Authorization, I may report such discrimination to the Kishwaukee College Chief Diversity Officer.

I understand, accept, and agree that, while I am under no obligation to sign this form and consent to these terms, my refusal to sign/consent or my withdrawal of consent to this Authorization to those identified above will make me ineligible to participate in Intercollegiate Athletics at Kishwaukee College.

EXPIRATION: This authorization is good until withdrawn or until superseded by execution of a subsequent form or until I cease participation in Intercollegiate Athletics at Kishwaukee College, whichever occurs first.

By signing below, I acknowledge and represent that I have read this Authorization for Use, Disclosure, and Release of Health Information in its entirety, understand it, and voluntarily sign it as my own free act and deed, and that I execute this Authorization fully intending to be bound by the same.



ACKNOWLEDGMENT AND CERTIFICATION OF COMPLIANCE WITH KISHWAUKEE COLLEGE INTERCOLLEGIATE ATHLETICS INSURANCE REQUIREMENTS

Student-Athlete’s Name: _____________________________ Sport(s): ________________________________________Current Medical, Dental, and Hospital insurance policies: Medical:Policy Holder Name: ________________________________ Relationship to Athlete: __________________________Policy Holder DOB:_________________________________Policy Holder Phone #_________________________________Primary Insurance Company: _________________________________________________________________________Policy Expiration Date: __________________________ Do you need a referral to see a specialist? YES NODoes this policy cover athletic related injuries? YES NO Do you have out of network benefits? YES NOInternational Students: Does this policy cover medical care in the United States? YES NO

Dental:Policy Holder Name: ________________________________ Relationship to Athlete: __________________________Policy Holder DOB:_________________________________Policy Holder Phone #_________________________________Primary Insurance Company: _________________________________________________________________________Policy Expiration Date: __________________________ Do you need a referral to see a specialist? YES NODoes this policy cover athletic related injuries? YES NO Do you have out of network benefits? YES NOInternational Students: Does this policy cover medical care in the United States? YES NO

Hospital:Policy Holder Name: ________________________________ Relationship to Athlete: __________________________Policy Holder DOB:_________________________________Policy Holder Phone #_________________________________Primary Insurance Company: _________________________________________________________________________Policy Expiration Date: __________________________ Do you need a referral to see a specialist? YES NODoes this policy cover athletic related injuries? YES NO Do you have out of network benefits? YES NOInternational Students: Does this policy cover medical care in the United States? YES NO

I attest that I have the above-referenced insurance coverages that are currently in full force and effect (the “Policies”). I understand that the Policies are my primary insurance coverage. I understand that maintenance of primary insurance during my participation in Intercollegiate Athletics at Kishwaukee College is a requirement for eligibility and participation. If there is a material change in coverage, I will notify Kishwaukee College Sports Medicine Department of this development and update the insurance information that is on file at Kishwaukee College within 10 days of such change. I understand and agree that, while Kishwaukee College has a secondary insurance policy (currently through 1st Agency Insurance) which may cover expenses not covered by my primary insurance, Kishwaukee College has no responsibility whatsoever for the payment of, or authorization to pay, medical expenses resulting in injuries that occur while participating in intercollegiate athletics at Kishwaukee College.

I authorize Kishwaukee College and 1st Agency Insurance to inspect or secure copies of any and all medical records necessary for evaluation of my coverage, including case history record, laboratory reports, diagnosis, X-rays, MRIs and any other data covering this and/or previous confinements and/or disabilities.

I authorize Kishwaukee College and 1st Agency Insurance to pay the medical vendors directly for any injury or medical care bill that is covered under the secondary insurance policy purchased by Kishwaukee College.

I have read and agree to comply with the provisions of the Acknowledgement of Insurance Requirements along with the KC Sports Medicine Bill Payment Policies and Procedures.

I understand, accept, and agree that, while I am under no obligation to sign this form and consent to these terms, my refusal to sign/consent or my withdrawal of consent to Acknowledgment and Certification of Compliance will make me ineligible to participate in Intercollegiate Athletics at Kishwaukee College.

By signing below, I acknowledge and represent that I have read, understand, and will comply with the Kishwaukee College Sports Medicine Bill Payment Policies and Procedures. I further acknowledge and represent that I have read this Acknowledgment and Certification of Compliance with Kishwaukee College Athletics Insurance Requirements in its entirety, understand it, and voluntarily provide my primary insurance information and sign as my own free act and deed, and that I execute this Acknowledgment and Certification of Compliance fully intending to be bound by the same.



First Agency, Inc.

5071 West H Avenue

Kalamazoo, MI 49009-8501

Phone (269) 381-6630

Fax (269) 381-3055

RETURN FORM WHEN COMPLETE TO: Kishwaukee CollegeAttention: Scott Kawall-Director Student Involvement

This form is to be completed by the 21193 Malta RoadParents, Guardians or Student Malta, IL 60150

Note: Complete all blanks on this form. Failure to complete all blanks will result in claims processing delays. If information is not applicable, indicate the reason it is not (e.g., deceased, divorced, unknown).

Name of Athlete Sport__________________________________

Social Security No or Passport No_________________________ Date of Birth____________________________

Home Address__ Cell Phone ( )_________________________

City__________________________________ State _________ Zip______________

College (Local) Address Home Phone ( )________________________

City__________________________________ State _________ Zip______________

PARENT/GUARDIAN/STUDENT INFORMATION FORM

FATHER/GUARDIAN INFORMATION

Father’s Name______________________________

Date of Birth_______________________________

Address________________________________

MOTHER/GUARDIAN INFORMATION

Mother's Name ______________________________

Date of Birth ________________________________

Address _________________________________

First Agency, Inc.

5071 West H Avenue

Kalamazoo, MI 49009-8501

AUTHORIZATION - To Permit Use and Disclosure of Health Information

FATHER/GUARDIAN INFORMATION

Father’s Name______________________________

Date of Birth_______________________________

Address________________________________

MOTHER/GUARDIAN INFORMATION

Mother's Name ______________________________

Date of Birth ________________________________

Address _________________________________

Is this Plan an HMO or PPO? Yes_____ No_____

Is pre-authorization required to obtain treatment?

Yes____ No_____

Is a second opinion required before surgery?

Yes_____ No_____

Is this Plan an HMO or PPO? Yes_____ No_____

Is pre-authorization required to obtain treatment?

Yes_____ No_____

Is a second opinion required before surgery?

Yes_____ No_____

This Authorization was prepared by First Agency, Inc. for purposes of obtaining information necessary to process a claim for benefits.

Upon presentation of the original or a photocopy of this signed Authorization, I authorize, without restriction (except psychotherapy notes), any licensed physician, medical professional, hospital or other medical-care institution, insurance support organization, pharmacy, governmental agency, insurance company, group policyholder, employer or benefit plan administrator to provide First Agency, Inc. or an agent, attorney, consumer reporting agency or independent administrator, acting on its behalf, all information concerning advice, care or treatment provided the patient, employee or deceased named below, including all information relating to, mental illness, use of drugs or use of alcohol. This Authorization also includes information provided to our health division for underwriting or claim servicing and information provided to any affiliated insurance company on previous applications. If this Authorization is for someone other than myself, that individual has given me the authority to act on his/her behalf as explained below.

I understand that I have the right to revoke this Authorization, in writing, at any time by sending written notification to my agent or to us at the above address. I understand that a revocation will not be effective to the extent we have relied on the use or disclosure of the protected health information or if my Authorization was obtained as a condition to determine my eligibility for benefits. Revocation requests must be sent in writing to the attention of the Claims Supervisor.

I understand that First Agency, Inc. may condition payment of a claim upon my signing this authorization, if the disclosure of information is necessary to determine the level or validity of the claim payment. I also understand, once information is disclosed to us pursuant to this Authorization, the information will remain protected by First Agency, Inc. in accordance with federal or state law.

I understand that I or my authorized representative is entitled to receive a copy of this authorization upon request.

This Authorization is valid from the date signed for the duration of the claim.

Name of Claimant (please print)______________________________________________________________________

Signature of Claimant (if claimant is 18 or older)_________________________________________________________

Name of Authorized Representative, or Next of Kin (please print)____________________________________________

Date Signature of Authorized Representative of Next of Kin Date_____________________________________________

Relationship of Authorized Representative or Next of Kin to Claimant___________________________________

Kishwaukee College Insurance Coverage

And Claim Procedure

Accidents do occur and we attempt to provide our student athletes with the very best possible care. Medical bills may be incurred when the student athlete is treated for bodily injury due to an accident, whether locally, during a road trip, or by a medical vendor in his or her own home area.

ONE FIRM STATEMENT:

The NCAA/NAIA/NJCAA discourages any college or university from providing coverage or paying the bills incurred for expenses related to illnesses or conditions which are NOT sustained as the direct result of an accident in our intercollegiate sports programs. (This INCLUDES pre-existing conditions and non-athletic injuries.)

INSURANCE COVERAGE:

The athletic accident insurance of Kishwaukee College provides EXCESS coverage for student athletes for accidents while participating in the play or official team practice of intercollegiate sports, including sponsored and authorized team travel.

CLAIM PROCEDURE:

All medical bills for a student athlete incurred as the result of an accident in the intercollegiate sports program will be sent directly to the home address, unless the college has instructed the medical vendors otherwise. In some cases the athletic department may get a copy of the bill, but in NO case will the athletic department be the primary place for the bill incurred to be sent.

A. Bills will be sent to the family’s insurance first. Insurance company will do one of two things:1. Honor the claim or portion of the bills incurred.2. Not honor the claim and send a letter of denial. An example may be that student athlete is no longer part of the

family group policy after attaining the age of 23.

B. If there remains a balance after the family insurance plan has contributed toward the claim, the family will send the claim sheet from the insurance company and a copy of the itemized bills incurred to the college’s Insurance Clerk, Amy Ludwig.

C. If a letter of denial is received from the family’s insurance plan, a copy of the letter of denial and copies of the bills incurred will be sent from First Agency to Kishwaukee College’s Insurance Clerk, Amy Ludwig. If no coverage is available, a letter from the family’s employer for verification will be necessary and must be sent to the Insurance Clerk.

D. If the bills incurred and not paid by the family’s insurance plan are large enough, the claim will be sent from Kishwaukee College to our insurance carrier office, First Agency, Kalamazoo, Michigan, for processing. If they need any additional information, family will need to assist First Agency in processing for the claim in the least possible amount of time. It is in the family’s best interest to have the claim settled promptly since all bills incurred are in student athlete’s name.

PLEASE NOTE: HMO’S AND PPO’S

If the primary family coverage is through an HMO (Health Maintenance Organization) or a PPO (Preferred Provider Organization) you MUST follow the proper procedures required by your plane in order for the college’s insurance to satisfactorily complete its portion of the claim. This is especially important if the plan requires pre-authorization to have the student athlete treated if he or she is out of the plan’s service area.

To have payable coverage on the student athlete, while a member of these organizations, the student athlete must use the authorized medical vendors from the list provided in their plan to the student-athlete’s family coverage. The coverage through Kishwaukee College is EXCESS coverage and does contain exclusions for those bills incurred that were “payable” by other insurance or plans. If the family chooses not to use the authorized medical vendor of their plan, they should be aware that the coverage will not be able to pay the bills incurred that would have been honored had they used the proper medical vendor. In some cases, this may mean that the student athlete needs to return to his/her plan’s service area for treatment.

At various times our athletic teams are several hundred miles from the Malta area, so families have completed a First Agency Insurance Parent/Student Information Form. Families should inform Kishwaukee College of the proper procedure of their insurance for handling an emergency. It is helpful for Kishwaukee College to know the plan’s particular definition of an emergency, i.e. if there are different insurance procedures to follow for treating a life-threatening emergency versus one such as a broken hand or dislocated shoulder that may not be life-threatening but does require attention of a medical professional.

The benefit period is one year after an injury date. If the claim exceeds $15,000, there is a four-year benefit period. All bills will be in the student athlete’s name and submitted first to the family’s insurance plan. If there remains a balance after the family’s plan has contributed toward the claim, the claim sheet from the insurance company and a copy of the itemized bills incurred must be sent to the insurance Clerk at Kishwaukee College. If the student athlete has no primary coverage, a letter of verification from the parent’s employer will be required before our insurance will process the claim.

All coaches and trainers will have a copy of student athletes’ insurance form with them at all times so that for HMO and PPO coverage, the student athlete is instructed to properly follow the procedures under his or her plan when medical services are necessary. Kishwaukee College policy is EXCESS coverage and will not pay bills incurred that were “payable” by other insurance coverage.

Emergency services are usually covered out of the plan’s service area. However, emergency/non-emergency situations need to be properly identified in regard to the HMO/PPO procedure. (An example would be a broken ankle being treated at a clinic instead of an emergency room - this would not be covered.)

It is suggested that whoever has contact with an injured student athlete, and is not sure of insurance coverage in the particular event, to refer to the Insurance Clerk, Amy Ludwig, who will contact First Agency to find out the information needed to properly complete the claims.

I HAVE READ AND UNDERSTAND 1ST AGENCY COVERAGE/CLAIM PROCEDURES FOR KISHWAUKEE COLLEGE

____________________________ ________________________________ __________________

Student Athlete Print Name Student Athlete Signature Date

KISHWAUKEE COLLEGEAGREEMENT TO DISCLOSE INJURIES AND ILLNESSES

In consideration of my being permitted to participate in intercollegiate athletics at KISHWAUKEECOLLEGE, I agree to fully disclose to the Kishwaukee College Sports Medicine staff, NorthwesternMedicine & Kishwaukee Hospital staff, team physicians, and/or medical consultants engaged bythem, any and all signs and symptoms of injuries and/or illness within twenty-four (24) hours of anaccident or incident upon recognition. I understand that any disclosed information will be utilized for the purpose of safeguarding my health as it pertains to my participation in intercollegiate athletics at Kishwaukee College. I also understand that any disclosed information will be treated as confidential under the guidelines of FERPA/HIPAA, and will only be shared with those directly involved in decisions related to my participation inKishwaukee College Athletics. I also verify that I have been given information pertaining to the signs, symptoms, prevention methods, and care of concussions. A copy of the Kishwaukee College Sport-Related Concussion protocol is available, for my reference, in the athletic training room.

Student-Athlete’s Name (please print): ____________________________________________

Student-Athlete’s Signature: ____________________________________________________

Sport: __________________________ Date: ________________________

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